RM11 Classification adjustments/ DRG exercises3 - LINDY AND

RM11 Classification adjustments/ DRG exercises3 - LINDY AND

RM11 Classification adjustments/ DRG exercises3 - LINDY AND RIC AND PEDJA RIC AND LINDY DRG Workshop Belgrade, 18-22.November 2013. DRG classifications around the world DRG Workshop Belgrade, 18-22.November 2013. Refinement of classes for resource homogeneity and clinical meaningfulness To compensate for classification failure The classification may not be able to measure the selection by one hospital of particular types of cases

Alternatively use additional flag for a price adjustment eg use of ventilation, Dx OR peer hospital flag. DRG Workshop Belgrade, 18-22.November 2013. Adjusting for classification limitations DRG Workshop Belgrade, 18-22.November 2013. Extra categories in Funding model outliers and exceptional cases. Many systems use outliers or exceptional case adjustments Well documented example is Victoria. Critics call it tinkering or interfering with the signals from the payment mechanism.

Others say that it adds precisions and fairness to the payment system. WHO IS RIGHT? DRG Workshop Belgrade, 18-22.November 2013. Outpatient and sub-acute caseload and DRGs Substitution and different models of care When does the care type change? What is the optimum? What is the norm? DRG Workshop Belgrade, 18-22.November 2013.

Admission and discharge policies IMPORTANT FOR CONSISTENT DATA APPLES WITH APPLES DRG Workshop Belgrade, 18-22.November 2013. Outpatient activity management tools Particularly important where substitution with inpatient services can occur eg Work up for a surgical admission The rehabilitation phase of a joint replacement Or even complete episodes Payment neutral incentives Guidelines and clear definitions of payment rules DRG Workshop Belgrade, 18-22.November 2013.

Simulation of adjustments for funding precision MODELLING, MODELLING, MODELLING Impact analysis Simulations Feedback and consultation plan and goal alignment DRG Workshop Belgrade, 18-22.November 2013. Outlier policies or classification changes The need to keep classes to manageable numbers Approaches to specifying outliers. DRG Workshop Belgrade, 18-22.November 2013. Clear Description of Costs Different health systems fund different

activities eg private providers usually include capital costs through depreciation, while public providers often have a separate funding mechanism some systems exclude (or unbundle) some highly variable/high cost components of care, like intensive care or prostheses The contracted prices should match the appropriate costs This might not happen if you adopt other countries costs (eg no blood costs in Australian data). DRG Workshop Belgrade, 18-22.November 2013. Specifying Contract Prices Usually: Relative Value Score (Cost Weight) Unit Price Cost weights are derived empirically from hospital Data

The unit price is negotiated - ideally all hospitals would have same unit price. - the unit price can be modified to reflect:- differences in cost between groups of hospitals - efficiencies of scale (eg Victoria) - transition arrangements ie blend the desired unit price with the hospitals average cost (as in the Irish Model and the private sector in Australia). DRG Workshop Belgrade, 18-22.November 2013. Other Hospital Products DRGs are only designed to describe acute admitted hospital episodes Different classifications are needed for other hospital services: Outpatients Long stay care Health promotion activities etc DRG Workshop Belgrade, 18-22.November 2013.

How good are DRGs Typically DRGs explain about 25%-40% of the variation in the costs of treating patients. Hospitals dont get a random sample of patients. Referral patterns and role delineation means that some hospitals treat sicker patients. Most systems have rules that provide extra payments so hospitals arent disadvantaged (ie share financial risk). With appropriate risk mitigation, funding models can explain over 80% of the variation in cost. DRG Workshop Belgrade, 18-22.November 2013. Rules to moderate financial risk Financial risk moderation for individual patients through outlier policy Same day policy Severity co-payments for specific subgroups within DRGs

Grants High cost patient adjustment funding pools DRG Workshop Belgrade, 18-22.November 2013. Outlier Policy Adjustments are made to the average rate for patients that stay in hospital for fewer days than or more days than the pre-defined times for each DRG Paid below the standard rate Frequency Paid the standard rate Paid above the standard rate High Outliers Low Outliers

Low Boundar y Average LOS Workshop LengthDRG of stay (days) High Boundary Belgrade, 18-22.November 2013. General Casemix Model Total $ Cost

(green) Funds (red) Low High Inlier Inlier Bounda Bounda ry Days in Hospital ry DRG Workshop Belgrade, 18-22.November 2013. Same Day Policy Differences between the costs of DRGs in different hospitals can be due to differences in the proportions of same day cases. This can be due to: Different types of cases in the DRG (COMPLEXITY) Differences in admission/discharge policy (eg admitting rather than treating on an outpatient basis.

Hospital clinical practice Efficiency Setting separate same day payment rate within a DRG can be used to prevent hospitals with mostly overnight patients being inappropriately disadvantaged. Same day payment rates are not always a good idea because they can discourage hospitals from moving to same day care where appropriate CLINICAL JUDGEMENT IS REQUIRED. DRG Workshop Belgrade, 18-22.November 2013. Co-payments for specific subgroups within DRGs Sometimes it is possible to identify subgroups within a DRG that cost more than the average. In these cases additional payments can be made. Co-payments are best used where groups of patients have higher than average cost in many DRGs. eg in Victoria

Mechanical ventilated patients Native Australians Using too many copayments reverts back to input based funding. DRG Workshop Belgrade, 18-22.November 2013. Grants or Block funding Higher costs for some hospitals can be: difficult to quantify (eg teaching hospital costs) or not directly related to activity (eg running an emergency department; the department must be kept open regardless of the level of activity) In such cases cash grants are often paid to hospitals in addition to activity based funding. Such grants are often easier to use in a public system than in a private system. DRG Workshop Belgrade, 18-22.November 2013.

Adjustment Funding Pools A set budget is put aside for allocating additional funding for specific patients based upon applications from hospitals Example 1: New Technology in Victoria AU$3million is set aside and hospitals apply for funding specific technologies in small numbers of patients Example 2: High Cost Patient Pool in Western Australia Approximately 20% of total hospital costs are required to treat the most expensive 5% of patients. These patients are difficult to fund under the casemix averaging approach. In WA hospitals are able to apply for additional funding for individual patients, but patients records are independently clinically reviewed and payment approved by an industry committee. DRG Workshop Belgrade, 18-22.November 2013. Risk Moderation While in

Transition When new activity based funding models are introduced not all hospitals are equally affected- some win and others lose. It is important to protect hospitals from extreme budgetary changes until they have time to adjust to the new funding model (ie find efficiencies). This is usually done by introducing transition grants or differential unit prices in the first few years. DRG Workshop Belgrade, 18-22.November 2013. Types of Casemix Models Casemix was initially developed as a prospective payment mechanism (ie this years activity determines this years funding). This approach is still widely used (eg USA Medicare, Victoria public hospitals and within the Private sector).

Prospective payment increases the incentives to achieve technical efficiency but reduces budgetary certainty for hospitals. Casemix can also be used as a retrospective payment mechanism (ie last years activity determines this years funding). This form of model is used in Ireland and New South Wales. Typically, in retrospective casemix models this years budget is set based upon last years budget plus growth. DRG Workshop Belgrade, 18-22.November 2013. Limiting the total amount of activity Experience suggests that health expenditure is extremely elastic and the potential to spend money on health care almost certainly exceeds any systems capacity to pay for that care. Most systems attempt to limit the amount of

activity funded by: setting activity caps (ie only funding activity to a certain level) or excluding funding for some health care intervention (eg cosmetic surgery) or introducing patient contributions DRG Workshop Belgrade, 18-22.November 2013. Variations around activity Targets Hospitals cannot exactly identify how many people will be admitted Funding models can be designed to accommodate this uncertainty by funding activity above target activity at a marginal rate and reducing funding at a marginal rate for hospitals failing to achieve target. DRG Workshop Belgrade, 18-22.November 2013.

Other Components of a successful casemix policy In the previous slides we have described the technical and process building blocks in developing a successful casemix policy. Non-technical issues are equally important: Openness and transparency Fairness Stakeholders involved Formal channels of review Willingness to listen and change DRG Workshop Belgrade, 18-22.November 2013. TOPICS

USE CASES FOR DRGS AND DESIRED CRITERIA THE GROUPING PROCESS DESIGN OF THE DRG ALGORITHM OVERVIEW OF NATIONAL DRG SYSTEMS PATTERNS OF ADOPTION OF DRGs WHERE/HOW WOULD AN I-DRG FIT IN? DRG Workshop Belgrade, 18-22.November 2013. MEASURING ACTIVITY LEVELS AND PAYING FOR THEM

PbR, ABF, PfP, Prospective payment, Casemix funding, Episode payment DRG Workshop Belgrade, 18-22.November 2013. GRANULARITY OF CATEGORIES Terms concepts +/- 600,000 Snomed CT terms +/- 300,000 Snomed RT concepts Classification categories

+/- 15,000 Diagnoses +/- 5,000 Procedures 500<->1000 DRGs 300<->400 ADRGs [+/- 200 SRGs - +/- 100 Clinical service types] 23 MDCs DRG Workshop Belgrade, 18-22.November 2013. Other Care types Rehabilitation, aged care, specialised nursing Chronic care, Mental health.

Service Related Groups SRGs Specialty utilisation measures DRG aggeregation Risk adjusted capitation groupings DCGs Care-staging-associated unbundled groupings eg DBCs DRG Workshop Belgrade, 18-22.November 2013. DRG Design Goals Clinical and cost homogeneity, Exhaustive and mutually exclusive ?????? Materiality, Transparency,

Data burden routine clinical/admin data Quality inputs required precision clinical, policy, and cost DRG Workshop Belgrade, 18-22.November 2013. Principles of Design Groups of healthcare activities which are: Iso-resource similar resource consumption Derived using readily available data

Clinically meaningful Manageable number of groups Describe actual/typical care patterns An eye to incentives for efficiency/quality ?? Mappable from other systems Benchmarking time series DRG Workshop Belgrade, 18-22.November 2013. Data Primary data sources Underlying classifications ICD/Morbidity, Procedures, Patient function Dependent variable E.g. EPISODE: Cost, length of Stay, price, charges Quality indicators Available design and test data sets DRG Workshop

Belgrade, 18-22.November 2013. Design process Formal timetable of representations, Design and response Germany, USA/Medicare (annual) Semi formal, biannual/annual processes Australia, UK, Nordic Engagement with stakeholders Hospitals, Clinicians, Policy, Commissioners Education DRG Workshop Belgrade, 18-22.November 2013. Statistical/classification tools Discriminant analysis (DA) Uses least squares methods

Regression models (multiple and logistic) relationship between multiple variables Artificial Neural Networks interconnected simple processors Tree-based algorithms (CART) Classification and Regression Trees (CART), CHAID, AUTOGRP (Yale) Rules for new groups Size, homogeneity DRG Workshop Belgrade, 18-22.November 2013. Clinical input and design Clinical Panels, representatives of medical

associations Australia, UK Formal representation from hospitals, medical associations USA, Germany Direct clinical design input and evaluation Practicing clinicians, full time design DRG Workshop Belgrade, 18-22.November 2013. Design Issues USE CASE ISSUES TECHNICAL APPROACH

Purpose Responsibilities Design principles Review and Revising process Currency, DRG unit of activity for payment Setting Independence Unbundling Iso-Resource Groupings Clinically meaningful

Comprehensive coverage Readily available data Quantitative rules Statistical Criteria Improving the Explanation of Variance DRG Workshop Belgrade, 18-22.November 2013. Grouping Process Data cleaning and input Data Edits Grouping Modelling Reporting Output

Standardise data Fixed file format One or multiple files Single patient (interactive) or Multiple patients (Batch) Face validity Consistency Warnings or failures Apply algorithm (s) Table driven Ungroupables Predictive models Concurrent models Observed v Expected Aggregate statistics Grouping variables Input file & grouping variables Expected values File format(s) DRG Workshop Belgrade, 18-22.November 2013.

DRG Workshop Belgrade, 18-22.November 2013. Nord DRG Respiratory grouping Logic DRG Workshop Belgrade, 18-22.November 2013. DRG Workshop Belgrade, 18-22.November 2013. The full version of the manual is found at www.nordclass.uu.se DRG Workshop Belgrade, 18-22.November 2013. Design Structure Major

Major CC, CC, Severity Severity Scale* Scale* Major Major CC, CC, Severity Severity Scale* Scale* DRG Workshop *APDRG, APRDRG Belgrade, 18-22.November 2013. Check list CC levels, multiple levels Minor, Intermediate, Major + multiple

Multiple procedures Procedure escalators, effect of ITCs Treatment packages E.g. renal dialysis, chemotherapy Chronic care Stable, non-stable, catastrophic events Generic design Primary care Cross over with outpatients DRG Workshop Belgrade, 18-22.November 2013. Options

Build your own DRG system Adapting another countrys system (no adaptation) International examples Adopt a grouper (e.g. Ireland) Adapt a grouper (e.g. Germany) Develop new grouper (e.g. UK, Australia) DRG Workshop Belgrade, 18-22.November 2013. Options (2) Adoption of a procedure classification Separate decision to Casemix classification E.g. Germany Joint decision e.g. Ireland, Portugal

International Standard Grouper Countries need to make decisions on grouper for domestic use (support national policies) Can make a separate decision for international comparisons Advantage in having the two related. DRG Workshop Belgrade, 18-22.November 2013. Clinician and other stakeholder input Clinical Panels, representatives of medical associations Australia, UK Formal representation from hospitals, medical associations USA, Germany Direct clinical design input and evaluation Practicing clinicians, full time design

DRG Workshop Belgrade, 18-22.November 2013. Overview of country specific variants Overview of country specific variants USA Medicares DRGs: evolution to MS-DRGs (Contributor: Julian Pettengill) Australia ARDRG Canada CMG Germany G-DRG England HRG Nordic DRGs AND OTHERS DRG Workshop Belgrade, 18-22.November 2013. International Evolution of DRGs G-DRGs v1-2 2003-2005

IR-DRGs v1-2 1998-2003 CMS DRGs v19-23 2000-2006 AP-DRGs v16-23 1999-2006 HCFA v6-18 1989-2000 AP-DRGs v8-15 1991-98 NACRI CHAMPUS/DoD 1988-98 NY-DRGs v5-7 1988-90

AR-DRGs v5 2002 AR-DRGs v4 1998-2001 AN-DRGs v1-3 1992-98 APR-DRGs v8-15 1991-98 HRG v4 2006 Inc Non-Acute HRG v3.5 2003 HRG v3

1997 HRG v1-2 1991-1994 Japan DPC Netherlands DBC Yale RDRGs 1989 HCFA v5 (4th Revision) 1988 (CC )exclusions England Portugal France

HCFA Version 1-4 1983- 1987 English Casemix Groups 1989 Nord DRG 1983-2006 Canada CMG 1983-2006 Adapted from Fetter R (1999) Casemix Classification Systems, Australian Health Review vol 22 no 2 DRG Workshop Belgrade, 18-22.November 2013. Medicares evolution to MS-DRGs

In 2008 Medicare adopted Medicare-severity DRGs From 1989 to 2007 differences in severity of illness were captured by presence or absence of a CC Early in the 2000s, many hospitals were beginning to take strategic advantage of opportunities for selection: Specialization in cardiac care and orthopedic surgery Development of physician-owned specialty hospitals CMS contracted with 3M to develop MS-DRGs, which: Expanded the number of DRGs from 500 to 750 Completely revised the CC and CC-exclusion lists Many base DRGs are split 3 ways, with MCC, CC, no/CC DRG Workshop Belgrade, 18-22.November 2013.

50 How CMS revised the CC list Is a given diagnosis (Dx), when present as a secondary Dx, a Major CC (MCC), a CC, or not a CC? Clinicians re-evaluated 13,549 Dxs to make initial MCC, CC, no CC assignments, and exclusions CMS measured resource impact for 3 patient groups: The target Dx is present as a 2nd DX, and the patient has: 1. 2. 3. No other 2nd Dx, or all other 2nd Dxs are not CCs At least one other 2nd DX that is a CC, but no 2nd Dx is a MCC At least one other 2nd DX that is a MCC

CMS calculated ratios of average charges for each group to average charges for all patients where no 2nd Dx is a CC. DRG Workshop Belgrade, 18-22.November 2013. 51 Results Group 1 Target 2nd Dx Benign hypertension N1 Group 2 Charge ratio

N2 Group 3 Charge ratio N3 Charge ratio CC Class 12,308 0.96 40,113

1.72 5,297 2.38 NonCC Obstructive bronchitis 7,003 1.42 32,276 2.19 13,355

3.04 CC Respiratory failure 5,332 2.10 118,937 2.94 223,054 3.34 MCC

DRG Workshop Belgrade, 18-22.November 2013. 52 Australian Refined DRG (ARDRG) AN-DRG v1.0 1992 updated annually 1998 bianually AR-DRG v6, 2008 Commonwealth of Australia, Department of Health and Ageing Clinical Casemix Committee National Casemix and Classification Centre (NCCC), University of Wollongong

23 MDCs, 665 DRGs Surgical heirarchy, principal diagnosis ICD-10-AM, ACHI Increase in groups with CC splits http://www.health.gov.au/internet/main/publishing.nsf/content/health-casemix-ardrg1.htm DRG Workshop Belgrade, 18-22.November 2013. AR-DRG CC Splits Complication and comorbidity level (CCL) patient clinical complexity level (PCCL) assignment CC Level

Description 0 Not a complication or comorbidity 1 Minor 2 Moderate 3 Severe 4 Catastrophic

DRG Workshop Belgrade, 18-22.November 2013. Criteria for Partitioning groupings ARDRG v5.1 Improved RID partitioning should achieve a minimum 5% increase in Reduction in Deviance (RID) for LoS and total cost. Where a discrepancy occurs between the LoS and Cost analyses, total cost will take precedence as the dependent variable if the LoS distribution from the cost data can be shown to approximate the LoS distribution for the morbidity data using a chi-squared goodness-of-fit test. Minimum national group size Size of DRGs created by partitioning an existing group should be the minimum of 10% of the original group and 500 estimated weighted separations (EWS). Where EWS = Estimated annual separations x 199899 NHCDC public sector cost weight

Difference in resource use New DRGs should differ in mean LoS by at least 2 days. If the longer stay group has a mean LOS of less than 4 days, then the shorterstay group mean should not exceed 50% of the longer-stay group mean. The difference in the mean Total Cost of DRGs formed by partitioning an existing DRG should be at least 20% of the mean Total Cost of the higher cost group. New group homogeneity The CV (LOS and Total Cost) for DRGs formed by partitioning and existing DRG should not exceed 1.3 x CV of the original group. Statistical Methodology for AR-DRG Version 5.0 DRG Workshop Belgrade, 18-22.November 2013. AR-DRG - Public Submission Statistical benefit Clinical currency

Alignment with health system priorities Implications for funding mechanisms Maintenance of classification system stability http://nccc.uow.edu.au/ardrg/ publicsubmission/index.html DRG Workshop Belgrade, 18-22.November 2013. Canada CMG Introduced 1983 Redevelopment in late 1980s, 1990 improved 1997, age & complexity overlays Age,CC not splits in CMGs 5 comorbidity levels 2001, ICD-10-CA introduced 2004 Redevelopment, 2007 CMG+

2007 CMG+, 2010 (CA 10th revision) 21 MCCs, 560 CMG 5 Factor adjustments Age Category, Comorbidity Level, Flagged Intervention, Intervention Event, Out-of-Hospital Intervention CACS, Ambulatory care DRG Workshop Belgrade, 18-22.November 2013. CMG+ Comorbidity Levels Comorbidities assign patient to one of 5 Comorbidity Levels, impact on resource consumption: Level 0 (0% to 24%) Level 1 (25% to 49%) Level 2 (50% to 74%) Level 3 (75% to 124%) Level 4 (125% or higher)

DRG Workshop Belgrade, 18-22.November 2013. CMG+ & RIW DRG Workshop Belgrade, 18-22.November 2013. Germany G-DRG Introduced 2003, adapted from AN-DRG v4.1 Annual revision via the structured dialogue 40% of all suggestions resulted in adjustments of the weights or the classification calculation of the relative weights of each DRG 2008, 1,137 DRGs, 26 Chapters Incorporates hours on mechanical ventilation DRG Workshop Belgrade, 18-22.November 2013.

G-DRG Functions 16 different types of functions, global spilt criteria:

OR-procedure not related to the principal diagnosis Weight at admission (for patients with an age < 1 year at admission) Specified procedures Complex procedures Complicating procedures Dialysis Polytrauma Procedure on several locations Intensive care therapy with a score above 552 points Intensive care therapy with a score above 1104 points Complex early rehabilitation therapy in geriatrics Early rehabilitation therapy Sequence of complex OR-procedures Specified OR-procedures, conducted at four different time levels Pre-transplantation hospital stay Complicating procedures in conjunction with an allocation to the pre-MDC. DRG Workshop Belgrade, 18-22.November 2013. England

Healthcare Resource Groups (HRG) Payment by Results Timetable Healthcare Resource Groups (HRG) and Service Classification Tools (SCT) Implementation of limited HRG Tariffs 2003/04 15 HRGs 2004/05 48 HRGs (piloting of tariff) Tariff based system 2005/2006 Objective 60% total NHS spend Acute Inpatients, Outpatients, A&E, Critical Care, Mental Health DRG Workshop Belgrade, 18-22.November 2013. Reimbursement Issues

Activity currency (Total Hospital Stay) Specialised Services (Hospital Tariff Uplift) Research and Development (Grants) Teaching (SIFT Formula) Critical care (per day payment) High length of stay patients (per day payment) Outpatients (per attendance) Chemotherapy (Drug Costs) High cost devices/drugs (Exception payments) DRG Workshop Belgrade, 18-22.November 2013. Scope of HRG4 More Settings Designed beyond admitted care Allocates the same procedures to HRGs irrespective setting

Increased Services Chemotherapy Critical Care Diagnostic Imaging Emergency & Urgent Care Interventional Radiology Rehabilitation Radiotherapy Specialist Palliative Care Supported by extended underlying OPCS classification (4.3) 2,000+ new codes introduced [25% increase] Non-surgical interventions DRG Workshop Belgrade, 18-22.November 2013.

HRG v3.1 to v3.5 to v4 V3.1 published 1997 V3.5 Revision October 2002 to May 2003 19 Clinical working Groups Initial Meetings Analysis Meetings Quality Assurance of Recommendations 572 to 610 HRGs HRGv4 1398 groups (A&E, OP, Chemotherapy etc) DRG Workshop Belgrade, 18-22.November 2013. English Casemix Classification Healthcare Resource Groups HRG Version 1 1991

HRG Version 2 1994 HRG Version 3 1997 HRG Version 3.5 2003 HRG Version 4 2007 Originally based on DRGs Developed within the National Health Service Based on groups of diagnoses and

surgery/treatments Originally used for treatments outside of resident area Now used to pay hospitals for their activity via a tariff DRG Workshop Belgrade, 18-22.November 2013. OTHERS FRANCE AUSTRIA JAPAN

THAILAND COMMERCIAL eg 3M MALAYSIA UNU ??VALUE IN A COMPREHENSIVE TABULATION DRG Workshop Belgrade, 18-22.November 2013. International Adoption/Development Country Diagnoses Procedures Casemix USA Australia Japan South Korea

Mexico South Africa Austria Belgium Denmark Finland France Germany UK Ireland Italy Netherlands Norway Portugal Spain Sweden Switzerland Hungary Romania Russia

ICD-9-CM ICD-10-AM ICD-10, ICF ICD-10 ICD-9-CM ICD-10 ICD-10 ICD-9-CM ICD-10 ICD-10 ICD-10 ICD-10 ICD-10 ICD-10-AM ICD-9-CM DBC ICD-10 ICD-9-CM ICD-9-CM ICD-10 ICD-10

ICD-10 ICD-10 ICD-10 ICD-9-CM, CPT4 ACHI HCFA/CMS-DRG, AP/R/APR-DRG AR-DRG, local variations DPG Korean DRG HCFA DRG, version 16 AP-DRG LKF AP-DRG (1995), APR-DRG (2002) Nord DRG/DAGS Nord DRG/Fin GHM/GHJ G-DRG HRG AR-DRG

HCFA-DRG, version 14 DBC-Groups Nord DRG HCFA DRG HCFA DRG Nord DRG AP-DRG Hungarian grouper AP-DRG, HCFA, IR-DRG AP-DRG Turkey, fyrMacedonia Croatia, Serbia Bosnia h. Singapore ICD-10-AM ICD-10-AM ICD-10-AM

ICD-10 ICD-10-AM ICD-10-AM ACHI ACHI ACHI ACHI ACHI ACHI Indonesia Malaysia Philippines Mongolia ICD-10 ? ICD-10 ? ICD-10 ? ICD-10 ?

ICD-9-cm v3 UNU DRG Workshop ICD-9-cm v3 UNU 2013. ICD-9-cm v3Belgrade, 18-22.November UNU ICD-9-cm v3 UNU KHIC-PH ICD-9-CM ICD-9-CM Austrian INAMI, /ICD-9-CM Nomesko NCSP CDAM SGVB OPCS

ACHI ICD-9-CM Dutch coding lists Norwegian code ICD-9-CM ICD-9-CM Nomesko ICD-9-CM ICPM-Hungary ICPM ICD-9-CM AR-DRG-V6 AR-DRG-V6 AR-DRG-V6 AR-DRG-V6 AR-DRG-V6 AR-DRG-V6 TOWARDS AN INTERNATIONAL DRG? EURO DRG PROJECT compatible goals?

UNU SIMPLIFIED GROUPER PROJECT collaboration? APPROACHING UPTAKE OF ICD-11 AND ICHI NEED FOR INTERNATIOAL COMPARISONS NEED FOR ACCESSIBLE - OPEN SOURCE MATERIAL COST OF MAINTAINING MULTIPLE PLATFORMS - THE BUSINESS CASE FOR LOCAL VARIANTS DRG Workshop Belgrade, 18-22.November 2013. POTENTIAL GOALS STANDARD INTERNATIONAL CORE At adjacent (general) DRG level. Approximately 400 categories Expandable to 800-1000 with complexity splits General CC tables but local levels values Local complexity splits. Initial scope - acute inpatients ??? but expandable to incorporate other care types

and setting independence. DRG Workshop Belgrade, 18-22.November 2013. Discussion???? Thank you DRG Workshop Belgrade, 18-22.November 2013. Statistical Evaluation .. Making it work. Performance of overall system Reduction in Variance (RIV), R-Squared, &/or RAR Log adjusted e.g. Reduction in Deviance (RID) Individual groups between hospitals Coefficient of Variance (CV), RIV Contribution to RIV Trimming Explanation of outlier data

DRG Workshop Belgrade, 18-22.November 2013. R-squared, or Coefficient of Determination DRG Workshop Belgrade, 18-22.November 2013. http://en.wikipedia.org/wiki/Coefficient_of_determination R does not tell whether the independent variables are a true cause of the changes in the dependent variable; omitted-variable bias exists; the correct regression was used; the most appropriate set of independent variables has been chosen; there is collinearity present in the data on the explanatory vari ables; the model might be improved by using transformed versions of the existing set of independent variables.

DRG Workshop http://en.wikipedia.org/wiki/Coefficient_of_determination Belgrade, 18-22.November 2013. n 1 WSS Adj R 2 1 n k TSS RIV with multiple factors n 1 WSS Adj R 1 n k TSS 2 Glantz, SA & Slinker, BK (1990), Primer of Applied Regression and Analysis of Variance, New York, McGraw-Hill Health Professions Division.

DRG Workshop Belgrade, 18-22.November 2013. Revision and Development Cycle of revision Minor and major revisions Additional data sources Inform new groups, use of other dependent variables Inform new data collection items Splitting groups Combining groups Multivariate analyses Comorbidities, multiple procedures DRG Workshop Belgrade, 18-22.November 2013.

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